HB 13-1221 Summary

• Pharmacy benefit managers, carriers, and their agents must provide pharmacies at least 7 days' written notice before conducting audits and must use licensed pharmacists to conduct audits requiring clinical or professional judgment.

• Audits cannot use extrapolation or statistical expansion techniques to calculate recoupment or penalty amounts, and pharmacies may submit documentation through facsimile, mail, or electronic submission if claims are disputed or denied.

• Pharmacy benefit managers and carriers must establish written appeals processes allowing pharmacies to challenge preliminary audit reports and resulting recoupments or penalties.

• Audits cannot exceed 24 months from the prescription submission or adjudication date unless longer periods are required by state or federal law, with time limits waived only when fraud or intentional misrepresentation is indicated through claims data review or investigation.

• Pharmacies cannot be subject to fund recoupment for clerical errors in required documents unless the error causes actual financial harm, and may use verifiable statements and medication administration records from authorized practitioners to validate pharmacy records and delivery.